Factors contributing to patient nonattendance at open-access endoscopy

Patient adherence to surveillance colonoscopy after endoscopic resection of colorectal polyps and factors associated with loss to follow-up

Background and study aims

Post-polypectomy surveillance colonoscopy (SC) plays an integral role in efforts to reduce colorectal cancer risk, but its effectiveness is invariably dependent on patient compliance. This study aimed to evaluate patient adherence to SC after endoscopic resection (ER) of polyps ≥ 20 mm and identify potential barriers associated with loss to follow-up.

Patients and methods

This was a single-center retrospective study evaluating adherence to SC after ER of polyps ≥ 20 mm between April 2018 to December 2021. Adherence to SC was defined as the proportion of patients who underwent follow-up colonoscopy. Multivariate logistic regression was performed to identify factors associated with loss to follow-up.

Results

A total of 959 patients (mean age 67 years; 47.9% women) underwent endoscopic resection of colorectal polyps ≥ 20 mm (mean size 33.2 ± 13.7 mm). Nearly half of the patients (n = 478; 49.8%) were lost to follow-up. On multivariate analysis, factors associated with a higher likelihood of SC non-adherence were: lack of a primary care physician (odds ratio [OR] 1.7;95% confidence interval [CI] 1.3- 2.3; P < 0.05), American Society of Anesthesiologists grade 3 or 4 (OR 1.4; 95% CI 1.1-1.9; P < 0.05), residence > 60 miles from the endoscopy suite (OR 1.6; 95% CI 1.2-2.3; P = 0.02), being referred by a physician outside of our healthcare system (OR 1.4; 95% CI 1.1-1.8; P = 0.01), and lack of written follow-up recommendations on the colonoscopy report (OR 3.6; 95% CI 1.4-10.2; P = 0.01).

Conclusions

Nearly half of patients undergoing ER of colorectal polyps ≥ 20 mm are lost to follow-up. We identified several patient- and healthcare-related factors as barriers to SC adherence. Strategies to address these issues and targeting of high-risk populations are urgently needed to enhance SC programs.

Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study

BACKGROUND

Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments.

OBJECTIVE

To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018.

MAIN MEASURES

Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments.

KEY RESULTS

The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively.

CONCLUSIONS

Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.

Racial Disparities in Endoscopy Cancellations During the COVID-19 Pandemic

INTRODUCTION

The coronavirus disease 19 (COVID-19) pandemic has disrupted healthcare delivery including elective endoscopy. We aimed to determine the prevalence of endoscopy cancellations in the COVID-19 era and identify patient characteristics associated with cancellation due to the pandemic.

METHODS

Medical charts were reviewed for adults who cancelled an outpatient endoscopic procedure from 5/2020 to 8/2020. The association of patient characteristics with cancellation of endoscopy due to COVID-19 was assessed using logistic regression.

RESULTS

There were 652 endoscopy cancelations with 211 (32%) due to COVID-19, 384 (59%) due to non-COVID reasons, and 57 (9%) undetermined. Among COVID-19 related cancellations, 75 (36%) were COVID-19 testing logistics related, 121 (57%) were COVID-19 fear related, and 15 (7%) were other. On adjusted analysis, the odds of cancellation due to COVID-19 was significantly higher for black patients (OR 2.04, 95% CI 1.07-3.88, p = 0.03), while patients undergoing EGD (OR 0.56, 95% CI 0.31-0.99, p = 0.05) or advanced endoscopy (OR 0.18, 95% CI 0.07-0.49, p = 0.001) had lower odds of cancellation. The odds of cancelling due to COVID-19 testing logistics was significantly higher among black patients (OR 3.12, 95% CI 1.03-9.46, p = 0.05) and patients with Medi-Cal insurance (OR 2.89, 95% CI 1.21-6.89, p = 0.02).

CONCLUSION

Black race is associated with an increased risk of COVID-19 related cancellation. Specifically, black patients and those with Medi-Cal are at increased risk of cancellation related to logistics of obtaining pre-endoscopy COVID-19 testing. Racial and socioeconomic disparities in access to endoscopy may be further amplified by the COVID-19 pandemic and warrant further study.

Short Message Service reminders reduce outpatient colonoscopy nonattendance rate: A randomized controlled study

BACKGROUND AND AIM

Nonattendance of outpatient colonoscopy leads to inefficient use of health-care resources. We aimed to study the effectiveness of using Short Message Service (SMS) reminder prior in patients scheduled for outpatient colonoscopy on their nonattendance rate.

METHODS

Patients who scheduled for an outpatient colonoscopy and had access of SMS were recruited from three clinics in Hong Kong. Patients were randomized to SMS group and standard care (SC) group. All patients were given a written appointment slip on the booking date. In addition, patients in the SMS group received an SMS reminder 7-10 days before their colonoscopy appointment. Patients' demographics, attendance, colonoscopy completion, and bowel preparation quality were recorded. Logistic regression was performed to identify predictors of nonattendance.

RESULTS

From November 2013 to October 2019, a total of 2225 eligible patients were recruited. A total of 1079 patients were allocated to the SMS group and 1146 to the SC group. The nonattendance rate of patients in the SMS group was significantly lower than that in the SC group (8.9% vs 11.9%, P = 0.022). There were no significant differences in their baseline characteristics and colonoscopy completion rate and bowel preparation quality. A trend towards a higher rate of adequate bowel preparation was observed in the SMS group when compared with the SC group (69.9% vs 65.8%, P = 0.053). Independent predictors for nonattendance included younger age, underprivilege, and existing diabetes.

CONCLUSIONS

An SMS reminder for outpatient colonoscopy is effective in reducing the nonattendance rate and may potentially improve the bowel preparation quality.

Will They Show? Predictors of Nonattendance for Scheduled Screening Colonoscopies at a Safety Net Hospital

BACKGROUND

Colonoscopy can reduce colorectal cancer-related mortality by up to 90% through early detection and polyp removal. Despite this, nonattendance rates for scheduled colonoscopies have been reported ranging from 4.1% to as high as 67% depending on the population studied.

AIM

The aim of the study was to measure the nonattendance rate for scheduled screening colonoscopy at a large safety net hospital and identify predictors of nonattendance within this patient population.

MATERIALS AND METHODS

This was a population-based study of 1186 adults who were scheduled to undergo screening colonoscopy at a safety net hospital as part of their routine preventative health program. Health systems variables were assessed including procedure time and scheduling patterns as well as patient-centered variables such as socioeconomic indicators and specific comorbid diagnoses. Associations with nonattendance were examined by univariate and multivariate logistic regression.

RESULTS

The overall rate of nonattendance for scheduled screening colonoscopy was 33%. A multivariate model was constructed to predict nonattendance revealing that private payer status [odds ratio (OR)=0.368, 95% confidence interval (CI): 0.225, 0.602] and prior colonoscopy (OR=0.371, 95% CI: 0.209, 0.656) were associated with greater attendance rates. Chronic obstructive pulmonary disease (OR=2.034, 95% CI: 1.239, 3.341), afternoon procedure time (OR=1.807, 95% CI: 1.137, 2.871), and a greater interval time between the date the colonoscopy was ordered and the date the colonoscopy was scheduled to occur (OR=1.005, 95% CI: 1.001, 1.009) were independently associated with nonattendance when controlling for age, sex, and race.

CONCLUSIONS

Specific predictors for scheduled screening colonoscopy nonattendance at a safety net hospital can be identified. These findings can be used to tailor community-based interventions to improve colorectal cancer screening rates.

Factors Associated with Missed and Cancelled Appointments in the Endoscopy Unit: Descriptive Study

Background and aim Canceled and missed appointments at the endoscopy unit affect the quality of the provided services and can negatively impact patient outcomes. Assessing the association between the various factors relating to nonattendance will show whether the defective aspects are organizational or personal, which is essential to improve the quality of the healthcare system. Moreover, this study will be of value in our region due to the current scarcity of studies in the Middle East. Methods A descriptive study was conducted at King Khaled University Hospital in Riyadh, Saudi Arabia. A database of participants was established from those who missed/canceled their outpatient endoscopy clinic appointment; purposive sampling was applied, excluding those who are under 14 years old. Demographic data and organizational factors (e.g., referred clinic and the lead time) were collected from the patients' files and a structured interview done by phone within 7-14 days of the missed/canceled appointment.  Results A total of 919 endoscopy procedures were scheduled in an eight-week period, and 179 procedures were missed/canceled (19.48%); 84% were missed, and 16% were canceled. The highest percentage of the population had a high-school diploma or less. The results showed that roughly half of the patients were unemployed. More than two-thirds of the patients had undergone an endoscopy within the past year or less. The majority stated that they underwent the procedure in a different facility, which might be due to various reasons, one of which could be justified as long lead time.  Conclusion An annual update of patients' files is suggested. Text messages can help serve as a reminder in addition to clear appointment instructions that will aid in minimizing the absence rates. Overbooking is recommended to decrease the lead time and increase clinic efficiency. Raising patients' awareness regarding the effect of missing appointments as well as upgrading the communication methods will assist in decreasing the rate of missed appointments.

A Theory-based Educational Pamphlet With Low-residue Diet Improves Colonoscopy Attendance and Bowel Preparation Quality

GOALS/BACKGROUND

Patients who "no-show" for colonoscopy or present with poor bowel preparation waste endoscopic resources and do not receive adequate examinations for colorectal cancer (CRC) screening. Using the Health Belief Model, we modified an existing patient education pamphlet and evaluated its effect on nonattendance rates and bowel preparation quality.

STUDY

We implemented a color patient education pamphlet to target individual perceptions about CRC and changed bowel preparation instructions to include a low-residue diet instead of the previous clear liquid diet. We compared the nonattendance rate over a 2-month period before and after the introduction of the pamphlet, allowing for a washout period during which pamphlet use was inconsistent. We compared the Boston Bowel Preparation Scale (BBPS) in 100 consecutive patients who underwent colonoscopy during each of the 2 periods.

RESULTS

Baseline characteristics between the 2 groups were similar, although patients who received the pamphlet were younger (P=0.03). The nonattendance rate was significantly lower in patients who received the pamphlet (13% vs. 21%, P=0.01). The percentage of patients with adequate bowel preparation increased from 82% to 86% after introduction of the pamphlet, although this was not statistically significant (P=0.44). The proportion of patients with a BBPS score of 9 was significantly higher in the pamphlet group (41% vs. 27%, P=0.03). There was no difference in adenoma and sessile serrated adenoma detection rates before and after pamphlet implementation.

CONCLUSIONS

After implementing a theory-based patient education intervention with a low-residue diet, our absolute rate for colonoscopy nonattendance decreased by 8% and the proportion of patients with a BBPS score of 9 increased by 14%. The Health Belief Model appears to be a useful construct for CRC screening interventions.

Stop Blaming the Weatherman! A Retrospective Study of Endoscopy Show Rates at a Midwest Urban Safety-Net Hospital

BACKGROUND

Weather patterns are well-known to affect human health and behavior and are often arbitrarily blamed for high no-show rates (NSRs). The NSR for outpatient gastrointestinal procedures ranges from 4% to 41% depending on the population and procedure performed. Identifying potential causes will allow for the optimization of endoscopy resource utilization.

AIM

The aim of this study was to evaluate the effects of a day of the year and weather conditions have on NSRs for outpatient endoscopic procedures at a safety-net hospital in Cleveland, Ohio, United States.

METHODS

A 12-month, retrospective cohort study of the NSR for outpatient endoscopic procedures was performed using local weather data from January 1, 2017 to December 31, 2017. Data was assessed by analysis of variance/t test, and the χ test was used to analyze weather impact on NSR.

RESULTS

A total of 7935 patients had an average overall NSR of 11.8%. Average NSR for esophagogastroduodenoscopies (EGDs) were 9.9%, colonoscopies 12.3%, and advanced endoscopy procedures 11.1%. The NSR was highest in April (15.3%, P=0.01) and lowest in September (9.0%, P=0.04). There is a greater likelihood of procedural no-show for colonoscopies compared with EGDs when mean temperatures were at or below freezing (P=0.02) and with snowfall (P=0.03). NSR were also high for EGDs on federal holidays (25%, P=0.03) and colonoscopies on days following federal holidays (25.3%, P<0.01). Day of the week, wind speed, presence of precipitation, wind chill, the temperature change from the prior day, and temperature (high, low, and mean) had no significant impact on NSR.

CONCLUSIONS

Our study demonstrates that scheduling adjustments on federal holidays, days when temperatures are below freezing, and snowfall may improve department resource utilization. These data, along with other variables that affect NSR for endoscopic procedures, should be taken into consideration when attempting to optimize scheduling and available resources in a safety-net hospital.

Utilization of Census Tract-Based Neighborhood Poverty Rates to Predict Non-adherence to Screening Colonoscopy

OBJECTIVES

Efforts to improve colorectal cancer (CRC) screening rates include recognizing predictors of colonoscopy non-adherence and identifying these high-risk patient populations. Past studies have focused on individual-level factors but few have evaluated the influence of neighborhood-level predictors. We sought to assess the effect of census tract-based neighborhood poverty rates on scheduled screening colonoscopy non-adherence.

METHODS

In this prospective observational cohort study, data from electronic medical records and appointment tracking software were collected in 599 patients scheduled to undergo outpatient CRC screening colonoscopy at two academic endoscopy centers between January 2011 and December 2012. Non-adherence was defined as failure to attend a colonoscopy appointment within 1 year of the date it was electronically scheduled. Neighborhood poverty rate was determined by matching patients' self-reported home address with their corresponding US census tract. Individual factors including medical comorbidities and prior appointment adherence behavior were also collected.

RESULTS

Overall, 17% (65/383) of patients were non-adherent to scheduled colonoscopy at 1-year follow-up. Neighborhood poverty rate was a significant predictor of non-adherence to scheduled screening colonoscopy in multivariate modeling (OR 1.53 per 10% increase in neighborhood poverty rate, 95% CI 1.21-1.95, p < 0.001). By incorporating the neighborhood poverty rate, screening colonoscopy non-adherence was 31% at the highest quartile compared to 14% at the lowest quartile of neighborhood poverty rates (p = 0.006).

CONCLUSIONS

Census tract-based neighborhood poverty rates can be used to predict non-adherence to scheduled screening colonoscopy. Targeted efforts to increase CRC screening efficiency and completion among patients living in high-poverty geographic regions could reduce screening disparities and improve utilization of endoscopy unit resources.

Predictors of No-show Rate in the GI Endoscopy Suite at a Safety Net Academic Medical Center

BACKGROUND/OBJECTIVES

Noncompliance with physician and procedure appointments is associated with poor disease control and worse disease outcomes. This also impacts the quality of care, decreases efficiency, and affects revenue. Studies have shown that no-show rates are higher in clinics caring for underserved populations and may contribute to poorer health outcomes in this group.

METHODS

We performed a 17-month retrospective observational cohort study of patients scheduled for outpatient procedures in the Gastroenterology endoscopy suite at the University of Florida Health, Jacksonville. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 6157 patients were scheduled to undergo different GI procedures during the study period. A total of 4388 (71%) patients completed their procedure, whereas 2349 (29%) failed to attend their appointment and were considered "no-show". There was a significant relationship between the visit attendance and race, insurance, gender, and marital status. Males had a higher no-show rate compared with females (30% vs. 28%; P<0.05). African Americans had the highest no-show rate (32%; P<0.05) amongst different races. Patients scheduled for surveillance colonoscopy (ie, history of polyps, IBD, Colon cancer) were more likely to show (78%) than those obtaining initial colorectal cancer screening (74%) or other indications (71%) (P<0.05).In the logistic regression model, patients with commercial insurance are more likely to show for their appointments than those with noncommercial insurance (eg, Medicare, Medicaid, City contract etc) [odds ratio (OR), 2.6; 95% confidence interval (CI), 2.2-3.0]. The odds of showing up are 1.7 times higher for married men compared with single men (OR, 1.7; 95% CI, 1.3-2.0). Similarly, married females are more likely to show up for appointment than single females (OR, 1.1; 95% CI, 0.9-1.3). We did not find significant association between the type of GI procedure (eg, colonoscopy vs. esophagogastroduodenoscopy vs. advanced endoscopic procedures) (P>0.05).

CONCLUSIONS

Predictors of no-shows for endoscopic gastrointestinal procedures included unpartnered or single patients, African American race and noncommercial insurance providers. Patients scheduled for surveillance colonoscopy had better adherence than initial screening. Further studies are required to better characterize these factors and improve adherence to the outpatient appointments based on the identified predictors.

A short telephone-call reminder improves bowel preparation, quality indicators and patient satisfaction with first colonoscopy

BACKGROUND AND STUDY AIMS

 Addition of a reminder program to conventional indications improves colonoscopy. The aim of this study was to evaluate the effectiveness of a short telephone call reminder (STCR) on a patient's first colonoscopy.

PATIENTS AND METHODS

 One day before colonoscopy, we made a STCR of < 10 minutes to 141 randomly selected patients of 258 recruited. The STCRs informed patients about the procedure date, indications for taking laxatives, and dietetic requirements. Questions were clarified only when patients asked directly. We evaluated bowel preparation, quality indicators, and patient satisfaction. Data were expressed as mean ± SD and percentages. Statistical differences were evaluated by Student's t and Chi squared tests; alpha = 0.05. All authors had access to the study data and reviewed and approved the final manuscript.

RESULTS

 The STCR group had better bowel preparation which was demonstrated by higher completion frequency (97.16 % vs. 82.05 %), in less time (4.52 ± 3.06 vs. 5.38 ± 3.03 hours) intake of laxative, and higher Boston's scale (7.66 ± 2.42 vs. 5.2 ± 1.65). Quality indicators of colonoscopy were better in patients that received a STCR [cecal intubation rate: 100.00 % vs. 87.18 %; polyp detection: 42.55 % vs. 9.4 %; and cecal arrival time (min): 12.09 ± 3.62 vs. 15.09 ± 5.02]. STCR patients were more satisfied (97.87 % vs. 55.56 %) and would repeat colonoscopy (21.99 % vs. 11.11 %).

CONCLUSIONS

 A simple additional step such as a STCR improves quality of bowel preparation, quality indicators, and satisfaction of patients undergoing their first colonoscopy. Clinical trial registry in Mexico City General Hospital: DI/16/107/3/108.

Appointment Wait Time, Primary Care Provider Status, and Patient Demographics are Associated With Nonattendance at Outpatient Gastroenterology Clinic

GOALS

We intended to identify the factors associated with missed appointments at a gastroenterology (GI) clinic in an academic setting.

BACKGROUND

Missed clinic appointments reduce clinic efficiency, waste resources, and increase costs. Limited data exist on subspecialty clinic attendance.

STUDY

We performed a case-control study using data from the electronic health record of patients scheduled for an appointment at the adult GI clinic at the Banner University Medical Center between March and October of 2014. Patients who missed their appointment during the study period served as cases. Controls were randomly selected from patients who completed their appointment during the study period. Analysis included univariate and multivariate logistic regression analysis.

RESULTS

Of 2331 scheduled clinic appointments, 195 (8.4%) were missed appointments. Longer waiting time from referral to scheduled appointment was significantly associated with missed appointment (AOR=1.014; 95% CI, 1.01-1.02; P<0.001). Patients with primary care providers (PCPs) were less likely to miss their appointment than those without PCPs (AOR=0.35; 95% CI, 0.18-0.66; P=0.001). Among patient demographic characteristics, ethnicity and marital status were associated with missed appointment.

CONCLUSIONS

Wait time, ethnicity, marital status, and PCP status were associated with missed GI clinic appointments. Further investigations are needed to assess the effects of intervention strategies directed at reducing appointment wait time and increasing PCP-based care.

Appointment-keeping behaviors and procedure day are associated with colonoscopy attendance in a patient navigator population

BACKGROUND

Patient navigator programs (PNP) have been shown to improve colonoscopy completion with demonstrated cost-effectiveness. Despite additional resources available to these patients, many still do not attend their colonoscopies. The aim of this study was to determine factors associated with colonoscopy attendance amongst patients in whom logistical barriers to attendance have been minimized through enrollment in a PNP.

METHODS

Retrospective case-control study of patients enrolled in a PNP for colonoscopy performed at a tertiary endoscopy center from 2009 to 2014. Cases were defined as patients who did not attend their first scheduled colonoscopy after PNP enrollment. Age- and gender-matched controls completed their first scheduled colonoscopy after PNP enrollment.

RESULTS

514 subjects (257 cases, mean age 57.1years, 36.6% males) were included. Patients who attended their colonoscopy were less likely to be Spanish-speaking (64.6% vs 78.2%, p=0.0003) and uninsured (0.4% vs 3.9%, p=0.006). Attendance rates were significantly lower for screening colonoscopies compared to an indication of surveillance or diagnostic (45.5% vs 65.3%, p<0.0001). Fewer patients attended colonoscopies scheduled on Monday (39.2% vs 52.1%, p=0.04) and in December (10.7% vs 52.3%, p<0.0001). On multivariate analysis, poor appointment-keeping behaviors, including a prior missed colonoscopy (OR 0.20, 95% CI 0.10-0.39) or missed office visit (OR 0.44, 95% CI 0.26-0.73) and procedures scheduled on Mondays (OR 0.51, 95% CI 0.27-0.94) were negatively associated with attendance.

CONCLUSIONS

Appointment-keeping behaviors, in addition to insurance-status, language-barriers and medical comorbidities, influence colonoscopy attendance in a PNP population. Patients scheduled for colonoscopies on Mondays or in December may require more resources to ensure attendance.

Improving Adherence to Screening Colonoscopy Preparation and Appointments: A Multicomponent Quality Improvement Program

Colorectal screening for cancer by colonoscopy is recommended for adults 50 years and older. Scheduling patients for sedated endoscopic procedures involves balancing physician schedules, room availability and equipment, proper patient preparedness, and necessary personnel. Both nonattendance and poor preparations contribute to inefficiency, wasted resources, and increased costs. We noted nonattendance rates ranging from 21% to 29%. As a first step, we examined patient factors associated with nonattendance using a retrospective case control study. Younger patients (<60 years), screening appointment, and insurance type were associated with nonattendance. On the basis of these findings, initial efforts focused on additional nurse strategies of follow-up contact and education for screening colonoscopies. As we improved attendance rate, concomitantly we discovered cancellation rates increasing. Subsequently, an interdisciplinary and interdepartmental quality improvement program has been ongoing to target a number of system-, nurse-, and patient-specific factors contributing to nonattendance and cancellations due to poor preparations. Rates have improved but require ongoing monitoring and surveillance. We describe the ongoing efforts and challenges aimed at both nonattendance and cancellations.

The role of a nurse telephone call to prevent no-shows in endoscopy

BACKGROUND AND AIMS

Preventing missed appointments, or "no-shows," is an important target in improving efficient patient care and lowering costs in gastrointestinal endoscopy practices. We aimed to investigate whether a nurse telephone call would reduce no-show rates for endoscopic appointments, and to determine if hiring and maintaining a nurse dedicated to pre-endoscopy phone calls is economically advantageous. Our secondary aim was to identify predictors of no-shows to endoscopy appointments.

METHODS

We hired and trained a full-time licensed nurse to make a telephone call to patients 7 days before their scheduled upper endoscopy or colonoscopy. We compared this intervention with a previous reminder system involving mailed reminders. The effect of the intervention and impact of other predictors of no-shows were analyzed in 2 similar preintervention and postintervention patient cohorts. A mixed effects logistic regression model was used to estimate the association of the odds of being a no-show to the scheduled appointment and the characteristics of the patient and visit. An analysis of costs was performed that included the startup and maintenance costs of the intervention.

RESULTS

We found that a nurse phone call was associated with a 33% reduction in the odds of a no-show visit (odds ratio, 0.67; 95% confidence interval, 0.50-0.91), adjusting for gender, age, partnered status, insurer type, distance from the endoscopy center, and visit type. The recovered reimbursement during the study period was $48,765, with net savings of $16,190 when accounting for the maintenance costs of the intervention; this resulted in a net revenue per annum of $43,173.

CONCLUSIONS

We found that endoscopy practices may increase revenue, improve scheduling efficiency, and maximize resource utilization by hiring a nurse to reduce no-shows. Predictors of no-shows to endoscopy included unpartnered or single patients, commercial or managed care, being scheduled for colonoscopy as opposed to upper endoscopy, and being scheduled for a screening or surveillance colonoscopy.

Preventing Endoscopy Clinic No-Shows: Prospective Validation of a Predictive Overbooking Model

OBJECTIVES

Patient absenteeism for scheduled visits and procedures ("no-show") occurs frequently in healthcare systems worldwide, resulting in treatment delays and financial loss. To address this problem, we validated a predictive overbooking system that identifies patients at high risk for missing scheduled gastrointestinal endoscopy procedures ("no-shows" and cancellations), and offers their appointments to other patients on short notice.

METHODS

We prospectively tested a predictive overbooking system at a Veterans Administration outpatient endoscopy clinic over a 34-week period, alternating between traditional booking and predictive overbooking methods. For the latter, we assigned a no-show risk score to each scheduled patient, utilizing a previously developed logistic regression model built with electronic health record data. To compare booking methods, we measured service utilization-defined as the percentage of daily total clinic capacity occupied by patients-and length of clinic workday.

RESULTS

Compared to typical booking, predictive overbooking resulted in nearly all appointment slots being filled-2.5 slots available during control weeks vs. 0.35 slots during intervention weeks, t(161)=4.10, P=0.0001. Service utilization increased from 86% during control weeks to 100% during intervention weeks, allowing 111 additional patients to undergo procedures. Physician and staff overages were more common during intervention weeks, but less than anticipated (workday length of 7.84 h (control) vs. 8.31 h (intervention), t(161)=2.28, P=0.02).

CONCLUSIONS

Predictive overbooking may be used to maximize endoscopy scheduling. Future research should focus on adapting the model for use in primary care and specialty clinics.

Factors Associated With Missed and Cancelled Colonoscopy Appointments at Veterans Health Administration Facilities

BACKGROUND & AIMS

Cancelled and missed colonoscopy appointments waste resources, increase colonoscopy delays, and can adversely affect patient outcomes. We examined individual and organizational factors associated with missed and cancelled colonoscopy appointments in Veteran Health Administration facilities.

METHODS

From 69 facilities meeting inclusion criteria, we identified 27,994 patients with colonoscopy appointments scheduled for follow-up, on the basis of positive fecal occult blood test results, between August 16, 2009 and September 30, 2011. We identified factors associated with colonoscopy appointment status (completed, cancelled, or missed) by using hierarchical multinomial regression. Individual factors examined included age, race, sex, marital status, residence, drive time to nearest specialty care facility, limited life expectancy, comorbidities, colonoscopy in the past decade, referring facility type, referral month, and appointment lead time. Organizational factors included facility region, complexity, appointment reminders, scheduling, and prep education practices.

RESULTS

Missed appointments were associated with limited life expectancy (odds ratio [OR], 2.74; P = .0004), no personal history of polyps (OR, 2.74; P < .0001), high facility complexity (OR, 2.69; P = .007), dual diagnosis of psychiatric disorders and substance abuse (OR, 1.82; P < .0001), and opt-out scheduling (OR, 1.57; P = .02). Cancelled appointments were associated with age (OR, 1.61; P = .0005 for 85 years or older and OR, 1.44; P < .0001 for 65-84 years old), no history of polyps (OR, 1.51; P < .0001), and opt-out scheduling (OR, 1.26; P = .04). Additional predictors of both outcomes included race, marital status, and lead time.

CONCLUSIONS

Several factors within Veterans Health Administration clinic control can be targeted to reduce missed and cancelled colonoscopy appointments. Specifically, developing systems to minimize referrals for patients with limited life expectancy could reduce missed appointments, and use of opt-in scheduling and reductions in appointment lead time could improve both outcomes.

Patient Non-adherence and Cancellations Are Higher for Screening Colonoscopy Compared with Surveillance Colonoscopy

BACKGROUND

A significant proportion of the eligible population is non-adherent to colonoscopy for colorectal cancer (CRC) screening.

AIMS

To define the demographic and clinical variables associated with non-adherence and multiple cancellations to scheduled colonoscopy within 1 year in a CRC screening and adenomatous polyp surveillance population.

METHODS

This was an observational cohort study of 617 consecutive patients scheduled to undergo colonoscopy at an outpatient academic tertiary care center for CRC screening or adenomatous polyp surveillance from January 2012 to September 2012.

RESULTS

Overall, 551 patients (89.3%) were adherent and 66 (10.7%) were non-adherent to scheduled colonoscopy at 1 year. The relative risk for non-adherence was 5.42 [95% confidence interval (CI) 2.74-10.75] in patients undergoing colonoscopy for screening compared to those for surveillance (16.7 vs. 3.5% non-adherence, respectively, P < 0.001). An indication of screening in comparison with surveillance was associated with non-adherence [odds ratio (OR) 12.69, 95% CI 4.18-38.51] and multiple cancellations (OR 2.33, 95% CI 1.27-4.31) by multiple regression analysis.

CONCLUSIONS

Patients undergoing colonoscopy for CRC screening are significantly less likely to attend their scheduled procedure within a year and have more procedure cancellations than those undergoing surveillance colonoscopy.

Prevalence and predictors of patient no-shows to outpatient endoscopic procedures scheduled with anesthesia

BACKGROUND

Demand for endoscopic procedures scheduled with anesthesia is increasing and no-show to appointments carries significant patient health and financial impact, yet little is known about predictors of no-show.

METHODS

We performed a 16-month retrospective observational cohort study of patients scheduled for outpatient endoscopy with anesthesia at a county hospital serving the safety-net healthcare system of San Francisco. Multivariate logistic regression analysis was performed to evaluate associations between attendance and predictors of no-show.

RESULTS

In total, 511 patients underwent endoscopy with anesthesia during the study period. Twenty-seven percent of patients failed to attend an appointment and were considered "no-show". In multivariate analysis, higher no-show rates were associated with patients with a prior history of no-show (odds ratio [OR] 6.4; 95% confidence interval [CI], 2.4- 17.5), those with active substance abuse within the past year (OR 2.2; 95% CI 1.4-3.6), those with heavy prescription opioids/benzodiazepines use (OR 1.6; 95% CI 1.0-2.6) and longer wait-times (OR 1.05; 95% CI 1.00-1.09). Inversely associated with patient no-show were active employment (OR 0.38; 95% CI 0.18-0.81), patients who attended a pre-operative appointment with an anesthesiologist (OR 0.52; CI 0.32-0.85), and those undergoing an advanced endoscopic procedure (OR 0.43; 95% CI 0.19-0.94).

CONCLUSION

In a safety-net healthcare population, behavioral and social determinants of health, including missed appointments, active substance abuse, homelessness, and unemployment are associated with no-shows to endoscopy with anesthesia.

Improving Nonattendance at Outpatient Pediatric Endoscopy Unit of a Tertiary Center

BACKGROUND AND OBJECTIVES

Failure to attend pediatric outpatient endoscopic procedures leads to inefficient use of resources, longer wait-list times, and delay in diagnoses. The causes for pediatric endoscopy nonattendance are not well studied. The aim of the study was to identify factors associated with failure to attend endoscopic procedures and to assess the value of quality improvement (QI) interventions implemented to improve pediatric endoscopy attendance.

METHODS

This was a continuous QI project. We collected nonattendance data from November 2011 to November 2013. Information collected included procedure type, age, sex, time on the waiting list, history of previous procedures, and reason for nonattendance. The following QI interventions were implemented sequentially: an appointment reminder letter, a telephone call 1 week before procedure, and creation of an electronic medical note dedicated to endoscopy appointment. Pareto charts and statistical process control charts were used for analysis.

RESULTS

From November 2011 to November 2013, we were able to decrease nonattendance from 17% to 11% (P = 0.005). No-show rate was reduced from 5% to 0.9% (P = 0.00001). There was no significant difference between attendees and nonattendees in relation to sex, age, or having a previous procedure. Longer waiting time (33 vs 26 days) was associated with increased risk for nonattendance (P = 0.0007). The most common causes for nonattendance were illness (31.5%), followed by caregiver/patients who no longer wanted the procedure (17.7%), and patients who improved (12.9%).

CONCLUSIONS

Applying QI methods and tools improved pediatric endoscopy attendance. Longer wait time for endoscopic procedures is associated with nonattendance. Given the increased pediatric endoscopy demand, strategies should be implemented to reduce wait time for pediatric endoscopy.

Satisfaction in open access versus traditional referral for upper endoscopy in children

OBJECTIVES

In traditional access endoscopy (TAE), patients are booked for endoscopy following a gastroenterology clinic assessment. In contrast, open access endoscopy (OAE) patients are seen for the first time on the day of the procedure, providing same day procedural consent. Controversy exists over the use of OAE in adults, both with the consent process and with patient satisfaction. No literature exists describing satisfaction with OAE in pediatrics. We therefore aimed to assess pediatric patient and caregiver satisfaction in OAE compared with TAE.

METHODS

Consecutive pediatric patients, and their caregivers, undergoing elective upper endoscopy from May to December 2012 at the Stollery Children's Hospital (Edmonton, Alberta, Canada) were consented for a cross-sectional survey. Seven preprocedure and 5 postprocedure questions were completed regarding mood and satisfaction with the wait time and the information provided. Group demographics and endoscopy wait times were collected.

RESULTS

Median wait time with OAE was less compared with TAE (57 days vs 196 days, P < 0.001). OAE patients reported worse mood preprocedure than TAE patients (35.3% vs 10.7%, P = 0.046). OAE caregivers and patients reported more mood disturbance if required to wait longer for endoscopy by attending clinic preprocedure (OAE caregivers 62.2%, OAE patients 64.7%).

CONCLUSIONS

OAE is associated with worse preendoscopy patient mood; however, children and caregivers seem concerned about longer wait times associated with TAE. Given the significantly shorter wait times in OAE, identifying methods to minimize present limitations of OAE will be useful to improve clinical practices in pediatric gastroenterology.

Organizational predictors of colonoscopy follow-up for positive fecal occult blood test results: an observational study

BACKGROUND

This study assessed the contribution of organizational structures and processes identified from facility surveys to follow-up for positive fecal occult blood tests [FOBT-positive (FOBT(+))].

METHODS

We identified 74,104 patients with FOBT(+) results from 98 Veterans Health Administration (VHA) facilities between August 16, 2009 and March 20, 2011, and followed them until September 30, 2011, for completion of colonoscopy. We identified patient characteristics from VHA administrative records, and organizational factors from facility surveys completed by primary care and gastroenterology chiefs. We estimated predictors of colonoscopy completion within 60 days and six months using hierarchical logistic regression models.

RESULTS

Thirty percent of patients with FOBT(+) results received colonoscopy within 60 days and 49% within six months. Having gastroenterology or laboratory staff notify gastroenterology providers directly about FOBT(+) cases was a significant predictor of 60-day [odds ratio (OR), 1.85; P = 0.01] and six-month follow-up (OR, 1.25; P = 0.008). Additional predictors of 60-day follow-up included adequacy of colonoscopy appointment availability (OR, 1.43; P = 0.01) and frequent individual feedback to primary care providers about FOBT(+) referral timeliness (OR, 1.79; P = 0.04). Additional predictors of six-month follow-up included using guideline-concordant surveillance intervals for low-risk adenomas (OR, 1.57; P = 0.01) and using group appointments and combined verbal-written methods for colonoscopy preparation instruction (OR, 1.48; P = 0.0001).

CONCLUSION

Directly notifying gastroenterology providers about FOBT(+) results, using guideline-concordant adenoma surveillance intervals, and using colonoscopy preparations instruction methods that provide both verbal and written information may increase overall follow-up rates. Enhancing follow-up within 60 days may require increased colonoscopy capacity and feedback to primary care providers.

IMPACT

These findings may inform organizational-level interventions to improve FOBT(+) follow-up.

A web-based appointment system to reduce waiting for outpatients: a retrospective study

BACKGROUND

Long waiting times for registration to see a doctor is problematic in China, especially in tertiary hospitals. To address this issue, a web-based appointment system was developed for the Xijing hospital. The aim of this study was to investigate the efficacy of the web-based appointment system in the registration service for outpatients.

METHODS

Data from the web-based appointment system in Xijing hospital from January to December 2010 were collected using a stratified random sampling method, from which participants were randomly selected for a telephone interview asking for detailed information on using the system. Patients who registered through registration windows were randomly selected as a comparison group, and completed a questionnaire on-site.

RESULTS

A total of 5641 patients using the online booking service were available for data analysis. Of them, 500 were randomly selected, and 369 (73.8%) completed a telephone interview. Of the 500 patients using the usual queuing method who were randomly selected for inclusion in the study, responses were obtained from 463, a response rate of 92.6%. Between the two registration methods, there were significant differences in age, degree of satisfaction, and total waiting time (P<0.001). However, gender, urban residence, and valid waiting time showed no significant differences (P>0.05). Being ignorant of online registration, not trusting the internet, and a lack of ability to use a computer were three main reasons given for not using the web-based appointment system. The overall proportion of non-attendance was 14.4% for those using the web-based appointment system, and the non-attendance rate was significantly different among different hospital departments, day of the week, and time of the day (P<0.001).

CONCLUSION

Compared to the usual queuing method, the web-based appointment system could significantly increase patient's satisfaction with registration and reduce total waiting time effectively. However, further improvements are needed for broad use of the system.

An academic medical center model for community colorectal cancer screening: the Centers for Disease Control and Prevention demonstration program experience

During 2005-2009, the Centers for Disease Control and Prevention funded five colorectal cancer (CRC) screening demonstration projects around the United States; only one was based in an academic medical center (AMC) rather than a health department. The Suffolk County Preventive Endoscopy Project (Project SCOPE) was a collaborative effort between Stony Brook University Medical Center (SBUMC) and the Suffolk County Department of Health Services. Project SCOPE's objective was to increase CRC screening among Suffolk County residents at least 50 years old who had inadequate or no insurance coverage for CRC screening. The demonstration application drew on the screening, diagnostic, and treatment resources of the AMC and the indigent populations using its outpatient clinics. Patients at 10 county health centers were a primary target for (previously inaccessible) colonoscopy screening. The project's organizational center was SBUMC's preventive medicine department, which was linked to SBUMC's large gastroenterology practice. The specific staffing, financial, and training issues faced by this project provide insights for others who are similarly interested in community engagement. During 40 months of screening, 800 indigent, culturally diverse patients were recruited, and they underwent colonoscopy. Challenges encountered included unreachable referred patients (425 patients; 28% of referrals) and medical ineligibility (e.g., symptomatic comorbid conditions). Pending legislation providing federal funding for a national program offers other AMCs the opportunity to adopt a model such as that proven feasible during Project SCOPE. The lessons learned may have broader application for fostering collaborative AMC partnerships and for enhancing recruitment and retention of participants through outreach.

How to overbook procedures in the endoscopy unit

BACKGROUND

Because nonattendance of outpatients scheduled for GI endoscopy is unavoidable, a frequently recommended solution involves overbooking patient appointments.

OBJECTIVE

To provide a set of numerical guidelines of how to overbook patients scheduled for endoscopy.

DESIGN

Cost-benefit analysis using stochastic modeling to estimate the total number of endoscopy appointments (including overbooking) that maximize the expected benefit from endoscopy.

PATIENTS

Subjects scheduled for GI endoscopy.

MAIN OUTCOME MEASUREMENTS

The number of endoscopies that should be scheduled under various scenarios of patient attendance rates, the number of available endoscopy slots, and the cost impact of missed appointments.

RESULTS

Overbooking can increase the expected benefit but never quite reaches the benefit that would be achieved, if all patients were perfectly reliable in meeting their scheduled appointments. The expected benefit of overbooking always comes to lie between the low benefit without overbooking and the high benefit associated with perfectly reliable patients. The less reliable the patient population, the more overbooking needs to take place. Overbooking should also expand with a decreasing cost impact of overbooked endoscopies. Overbooking is most beneficial in large endoscopy units. This article provides a table with a large set of numerical examples for different scenarios of overbooking that cover endoscopy units of diverse sizes and patient attendance rates.

LIMITATIONS

The analysis does not take into account individual patient characteristics that may affect attendance rates.

CONCLUSION

This analysis yields a set of estimates for overbooking that can be readily applied to a large variety of endoscopic units.

Factors associated with non-attendance at outpatient endoscopy

OBJECTIVE

Non-attendance at endoscopy procedures leads to wasted resources and increased costs. The purpose of this study was to investigate the factors associated with non-attendance.

MATERIAL AND METHODS

All patients who attended the outpatient clinic for gastroscopy or colonoscopy examinations were included in the study. Patients who missed their appointment were identified and their data were collected prospectively. Patients who kept their appointment in the same period of time served as controls.

RESULTS

Between August 2002 and February 2003, 1051 gastroscopies and 756 colonoscopies were scheduled. A total of 265 patients (14.7%) missed their appointment. No significant differences were found between attendees and non-attendees for mean age, gender, type of examination and day of the week on which the examination was scheduled. The time on the waiting list was longer in patients who did not keep their appointment than in those who did. Fewer appointments were missed in patients with a preferent referral, and among patients referred by their general practitioner a higher percentage failed to keep their appointment compared with those referred by a specialist. In the multivariate analysis, length of time on the waiting list and the source of referral were the only two independent predictive factors for non-attendance.

CONCLUSIONS

A longer time on the waiting list and referral by a general practitioner are factors associated with patients failing to keep their endoscopy appointment.

Colonoscopy completion in a large safety net health care system

BACKGROUND & AIMS

Anecdotally, patients in safety net health care systems have difficulty completing screening and diagnostic colonoscopies, but this is poorly characterized. It is important to understand this phenomenon to improve low rates of colorectal cancer screening in vulnerable populations and to ensure that patients with signs and symptoms complete medically indicated colonoscopic evaluations.

METHODS

We performed a 6-month retrospective review of outpatient endoscopy laboratory scheduling and procedure logs and electronic medical records at Denver Health Medical Center (DHMC), a large safety net health care system, to describe rates and sociodemographic predictors of colonoscopy nonattendance and inadequate (fair/poor) bowel preparation. Predictor variables included patient age, gender, race/ethnicity, procedure indication, and insurance type.

RESULTS

The nonattendance rate was 41.7% for all scheduled outpatient colonoscopies without difference between screening and diagnostic procedures. Consistent with non-safety net systems, the rate of inadequate bowel preparation was 30.2%; however, the rate of poor bowel preparation that absolutely precluded an exam was 9.9%. Correctional care patients had markedly higher rates of nonattendance and inadequate bowel preparation compared with other groups.

CONCLUSIONS

A very large proportion of patients scheduled for colonoscopy in a large safety net health care system do not attend their procedures, and among those who do, there is a high rate of inadequate bowel preparation leading to incomplete and aborted evaluations. Interventions are needed to promote the more efficient use of a limited and expensive resource and to achieve higher rates of screening and medically indicated diagnostic colonoscopies in vulnerable patient populations.